Baptist Memorial Hospital Desoto

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 44086 Based on staff interviews, medical record reviews, policy and procedure reviews, document review of the facility’s Surge Plan, Surge Plan Job Action Sheet, Medical Staff Leadership Council Meeting Minutes, Executive Summary - Surge Plan, Surge Plan Timeline, Surge Capacity Plan Test Change Summary and Recommendations, and the Emergency Department (ED) logs, the Governing Body failed to operate the hospital in an effective manner to meet the needs of patients presenting to the ED during times when surges of individuals presented for evaluation and treatment of potential emergency medical conditions. Additionally, the Governing Body failed to ensure identified Quality Improvement Performance Improvement (QA/PI) program corrective actions were implemented timely and evaluated for effectiveness. This effected six (6) of 20 sample patients and had the potential to impact all patients presenting to the ED (Patients #1, #10, #13, #14, #15, and #16). Findings Include: An interview with facility ED Director on 06/12/2024 at 3:15 p.m. to 3:40 p.m. confirmed on 06/05/2024 the hospital census was at capacity and their ED census was 171, which included a high rate of critical holds. When questioned about facility protocols when at capacity, the ED Director confirmed they have a “Surge Capacity Plan,” which is activated to try to mitigate long wait times and delays in care, and further confirmed she does not recall activating the surge plan on 06/05/2024. The ED Director could not confirm the ED was provided additional staff or other resources to monitor waiting patients for deterioration of their presenting complaints or that the facility implemented its “Diversion Policy” or “Evaluation and Transfer of Patients with Emergency Medical Conditions Policy” to ensure patient needs were met. An interview with ED Charge Nurse on 06/12/2024 at 4:20 p.m. confirmed she was working as charge nurse on 06/05/2024. The ED Charge Nurse does not recall implementing the surge plan or script announcement on 06/05/2024 when the ED was at capacity. Further interview revealed the ED Charge Nurse could not confirm the ED was provided with additional staff or other resources to ensure ongoing assessment of waiting patients and could not submit any documented evidence of ongoing assessment of patients that were waiting in the ED lobby for their medical screening exams after they were triaged. An interview with the Director of Quality Review (DQR) on 06/13/2024 at 2:20 p.m. confirmed the facility’s “Surge Capacity Plan” was approved 02/11/2020 and at the time of the survey a performance improvement project (PIP) in place to pilot some changes. The DQR also confirmed the ED Director reported she did not recall utilizing/implementing the “Surge Capacity Plan” on 06/05/2024. The DQR could not confirm the facility provided additional staff or other resources to monitor waiting patients for deterioration of their presenting complaints or that the facility implemented its “Diversion Policy” or “Evaluation and Transfer of Patients with Emergency Medical Conditions Policy” to ensure patient needs were met. An interview with Nurse Practitioner (NP) #1 on 06/13/24 at 4:45 p.m. confirmed Patients #1, #10, #13, #14, #15, and #16 were triaged, had an initiated Medical Screening Exam (MSE) and testing, then sent back to the ED lobby to wait for test results and completion of the MSE/treatment plan on 06/05/2024. NP #1 also confirmed there was no documented evidence of the patients being reassessed/monitored by an ED staff member after initial testing orders placed during triage. An interview with the Director of Quality (DOQ), on 06/13/2024 at 5:20 p.m. also confirmed patients #1, #10, #13, #14, #15, and #16 were triaged, had a MSE initiated and testing while in triage, then sent back to the ED lobby to wait for test results and completion of the MSE/treatment plan on 06/05/2024. The DOQ also confirmed there was no documented evidence of the patients being reassessed/monitored by an ED staff member after initial testing orders placed during triage. An interview with the Chief Nurse Officer (CNO) on 06/14/2024 at 12:05 p.m. confirmed the facility has an active “Surge Capacity Plan” and a pending revision to the plan. The CNO states, “We are still trying to gather consistent National Emergency Department Overcrowding Scores (NEDOCS) from our charge nurses and then consistently follow up from those scores.” The CNO confirmed the facility had a “Capacity Call” at 8:00 a.m. on 06/05/2024 to review the following: current house wide census, which was around 305, current ED holds, which was around 17 holds, the type of available staffed beds, which was zero (0), any scheduled operating room cases that will need beds, any Intensive Care Unit (ICU) cases that could be stepped down, which was zero (0) for the day, any step-downs that could go to medical-surgical (M/S) unit, Nurse patient ratios: M/S one (1) nurse to eight (8) patients (1:8), fully staffed, Stepdown ratio 1:4-5, ICU 1:2-3 with about 28-30 census, Critical Care Unit (CCU) 1:1. The CNO said a “snapshot of the census” is obtained at 5:30 a.m. or 6:30 a.m. so it can be reviewed and discussed at the “Capacity Call”. The CNO could not confirm or provide any evidence that the facility deployed additional staff or other resources to the ED to ensure ongoing assessment/monitoring of patients for the potential deterioration of their presenting complaints while waiting for extended periods of time in the ED waiting room for an open ED bed to complete their medical screening exam (MSE) or that the facility followed its “Diversion Policy” when at capacity. In an additional interview with the Director of Quality Review (DQR) on 06/14/2024 at 12:10 p.m. it was confirmed the facility had no documented evidence of the NEDOCS tracking log being implemented as required by the “Surge Capacity Plan” on 06/05/2024. The DQR further confirmed the facility had a daily 8:00 a.m. “Capacity call” to discuss the “snapshot census report” and patient movement, and at 8:15 a.m. all nurse leaders have a “huddle meeting” to discuss patient acuity, moves, safety initiatives such as restraints and one (1) on one (1) (1:1) patient needs, lines, foleys [catheters], pending tests, and surgeries. The DQR confirmed this is part of surge management and satisfied the surge plan. However, the facility did not implement/follow the capacity surge plan for a Level 2- Red, based on an ED census of 171, to ensure patients were monitored for possible deterioration of their presenting complaints while waiting in the ED waiting room for six (6) to 11 hours or deploy additional staff resources. Review of document titled, “Surge Capacity Plan,” dated 02/21/2023 submitted by ED Director reveals the ED unit has a plan for monitoring the influx of patients into levels of three (3) categories: Level 1 Yellow Extremely busy, not overcrowded, 61-100 patients; Level 2 Red Overcrowded to Extremely Overcrowded,101-180 patients; Level 3 Black Dangerously Overcrowded, 181-260 patients. The plan includes an “NEDOCS Tracking Log” to be documented daily to score surge levels. The Emergency Department ED log revealed the ED was at “Level Two (2) [based on ED log census of 171 patients] - Red (NEDOCS 101-180) Overcrowded to Extremely Overcrowded” defined roles and responsibilities included “...Make reassignments change RN [Registered Nurse] Ratios ...non-bedside nurses to assist in ED...evaluate alternative treatment spaces ...Assign additional staff to ED...Waiting Room - vitals up to date...Need Personal Care Assistant, (PCA)...Ongoing evaluation of NEDOCS score every 2 hours ...” There was no documented evidence of the facility’s activation/implementation of “Surge Capacity Plan” for the Emergency Department, no documented evidence of the “NEDOCS Tracking Log” completed per hospital plan, and no evidence of deploying additional staff/resources to the ED on 06/05/2024. During exit conference on 06/18/2024 with the Director of Risk Management, Director of Quality Review, Chief Nursing Officer and the Chief Executive Officer, survey findings were discussed, and no further documents were presented for review. Cross Refer to A-092, A263 and A1100 for additional findings.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 44086 Based on staff interviews and document review of the facility’s Surge Plan, Medical Staff Leadership Council Meeting Minutes, Executive Summary - Surge Plan, Surge Plan Timeline, Surge Capacity Plan Test Change Summary and Recommendations, the hospital failed to implement corrective actions after areas of needed improvement were identified and recommended following data collection and analysis. Findings Include An interview with the Director of Quality Review (DQR) on 06/13/2024 at 2:20 p.m. confirmed the facility’s “Surge Capacity Plan” was approved 02/11/2020 and a Performance Improvement Project (PIP) in place to pilot some changes. No documents were presented for review. An interview with the Chief Nurse Officer (CNO) on 06/14/2024 at 12:05 p.m. confirmed the facility has an active “Surge Capacity Plan” and a pending revision plan. The CNO stated, “We are still trying to gather consistent National Emergency Department Overcrowding Scores (NEDOCS) from our charge nurses and then consistently follow up from those scores.” Review of a hospital document titled, “Medical Staff Leadership Council” meeting minutes dated 02/11/2020 revealed the ED Surge Plan submitted by the Quality Director was approved by the council and a motion was made and seconded to accept the ED surge plan and flowcharts. Review of documented titled “Surge Plan Timeline” revealed a timeline for improvements with Senior Leader Presentation on 02/14/2023, Director/Managers Presentation on 02/21/2023, Test of Change March 06-13, 2023, Evaluate March data April 10-14, 2023, and re-evaluate and make changes and present data to director/managers to hardwire process by 04/18/2023. Review of the facility document titled, “Surge Capacity Plan Test of Change Summary and Recommendations”, dated 07/21/2023, revealed a test was launched March 6-31, 2023, and extended through May and June 2023 with findings and recommendations noted. There was no further documentation provided to indicate recommendations were presented to Senior leaders, approval of changes, performance improvement projects implemented, and no recent tracking and trending of outcomes with the Surge Capacity Plan since 07/21/2023. During exit conference on 06/18/2024 with the Director of Risk Management, Director of Quality Review, Chief Nursing Officer and the Chief Executive Officer, survey findings were discussed, and no further documents were presented for review. Cross reference to A-283, A-309 and A-1100 for additional findings.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 44086 Based on staff interviews, medical record reviews, policy and procedure reviews, document review of the facility’s Surge Plan, Medical Staff Leadership Council Meeting Minutes, Executive Summary - Surge Plan, Surge Plan Timeline, Surge Capacity Plan Test Change Summary and Recommendations, and the Emergency Department (ED) logs, the hospital failed to re-assess Emergency Department (ED) patients after their initial triage assessment and initiated screening by a provider. Patients were placed back in the ED lobby waiting area for an open bed in the ED to complete their medical screening exams. During these extended wait times Patients #1, #10, #13, #14, #15, and #16 were not monitored for potential deterioration of their presenting complaints. The hospital did not implement and follow its own policies and procedures related to diversion and evaluation and transfer of patients with Emergency Medical Conditions (EMC). This deficient practice affected six (6) patients (Patients #1, #10, #13, #14, #15, and #16) and had the potential to impact all patients served. Findings Include: Review of Patient #1’s medical record triage notes dated 06/05/2024 by the triage nurse confirmed Patient #1 was called to triage with no answer at 2:04 p.m. (reported patient was in the bathroom). Medical record triage note confirmed Patient #1 was triaged at 2:18 p.m. with a complaint of abdominal pain and vaginal bleeding. Patient #1 reported she was told on 05/13/2024 at eight (8) week appointment with her Obstetrician that there was no fetal heartbeat. Patient #1 was assigned a triage acuity level three (3). Medical Record ED Provider Note by Nurse Practitioner (NP) #1 at 2:17 p.m. documented “ ...I have reviewed the triage data and briefly greeted the patient. I will order initial workup and care so that the patient can be effectively cared for by another teammate. The patient appears to be in a safe condition to be seen by the next available provider ...”. Lab and imaging tests were ordered, and Tylenol tablet 1,000 milligrams (mg) orally given at 2:21 p.m. Patient #1 was moved to the ED lobby waiting area at 2:51 p.m. No documented evidence Patient #1 was reassessed or monitored while waiting for test results and completion of MSE. Review of Patient #1’s imaging report dated 06/05/2024 at 3:37 p.m. revealed “thicken hyper vascular endometrium ...findings suggestive of retained products of conception.” Patient #1 signed a refusal of services/against medical advice document at 10:16 p.m., eight (8) hours and 27 minutes after last contact with ED staff. An interview with Nurse Practitioner (NP) #1 on 06/13/2024 at 4:35 p.m. confirmed NP #1 was the provider for Patient #1 and initiated the MSE and ordered diagnostic labs and imaging. She further confirmed Patient #1 was sent back to the waiting room after completing her labs and imaging until an ED room was available for a provider to review test results and complete the MSE. NP #1 could not recall if the patient was taken to a room for review of results with a provider and disposition plan. NP #1 also confirmed that the documented location of the patient “Room Screen” means the patient was returned to the waiting room until an ED room was available. Review of the medical record for Patient #10 revealed the patient presented to the ED at 1:52 p.m. on 06/05/2024 with a complaint of shortness of breath and headache for several days. Patient #10 was triaged with an acuity level of two (2) and the MSE was initiated by NP #1 at 2:12 p.m. Medications administered, Reglan (treatment of gastroesophageal reflux disease) 10 milligrams (mg) oral, Benadryl (treatment for hives, common cold, drug allergy, anaphylaxis, etc.) 25 mg oral, Apresoline (treatment for heart failure) 10 mg intramuscular. Lab and Radiology testing was ordered and after testing patient #10 was sent to the ED lobby to wait for an ED room. There is no documented evidence of an attempted patient encounter until 06/06/2024 at 1:35 a.m. when the ED staff phoned Patient #10 after she did not answer when her name was called in the ED waiting room. The medical record revealed the patient went without staff contact for 11 hours and 16 minutes before the ED staff realized the patient had eloped from the ED. Triage Algorithm for an acuity level two (2) states, “ ...High Risk Situation ...put in last open bed ...”. Review of the facility policy and procedure titled, “Triage Acuity Classification System Problem Specific Guidelines,” dated last review of 05/2022, revealed each patient presenting to the ED requesting emergency services is triaged and receives a MSE by the ED physician or his/her designees (Nurse Practitioner or Physician’s Assistant) ... facility uses the 5-level Emergency Severity Index (ESI) triage leveling system...”. The algorithm does not include time frames for initiating care except for Level one (1) immediate life-saving interventions required, Level two (2) is High Risk Situation, would put in last open bed, Level three (3) many resources needed (testing). Review of the medical record for Patient #13 revealed the patient presented to the ED on 06/05/2024 at 2:51 p.m. with a complaint of abdominal pain with nausea/vomiting. Patient #13 was triaged with an acuity level of three (3) and the MSE was initiated by NP #1 at 3:10 p.m. Medication administered was Phenergan (treatment of allergies and motion sickness, sedative before surgery and can also help control pain, nausea, and vomiting) 25 mg oral. Lab and radiology testing was ordered, and after testing Patient #13 was placed back in the ED lobby at 3:46 p.m. to wait for an ED room. There is no documented evidence of an attempted/patient encounter until 06/06/2024 at 1:50 a.m. The medical record revealed the patient went without staff contact for 10 hours and four (4) minutes before the ED staff realized the patient eloped from the ED. Review of the medical record for Patient #14 revealed the patient presented to the ED on 06/05/2024 at 1:18 p.m. with a complaint of intermittent, frontal headache along with dizziness and intermittent nausea for the past three (3) weeks. Patient #14 was triaged with an acuity level of three (3) and the MSE was initiated by NP #1 at 1:52 p.m. Medications administered were Reglan 10 mg oral, and Benadryl 25 mg oral. Lab and radiology testing was ordered, and patient was place back in the ED lobby at 2:50 p.m. to wait for an ED room. There is no documented evidence of an attempted/patient encounter until 06/06/2024 at 1:40 a.m. The medical record revealed the patient went without ED staff contact for 10 hours and 50 minutes before signing out Against Medical Advice (AMA). Review of the medical record for Patient #15 revealed the patient presented to the ED on 06/05/2024 at 12:16 p.m. with a complaint of bilateral flank pain and urinary frequency. Patient #15 was triaged with an acuity level of three (3). The MSE was initiated by NP #1 at 4:07 p.m. Medication administered was Toradol (treatment of kidney stone, migraine, low back pain, and tension headache) 60mg/milliliter (ml) intramuscular. Lab testing was ordered, and the patient was placed in room 22 at 4:07 p.m. Medical record review revealed the patient was sent back to the ED lobby at 4:50 p.m. to wait for an ED room. Review of the medical record revealed there was no documented evidence of an attempted/patient encounter until 10:36 p.m. The medical record revealed the patient went without staff contact for six (6) hours and 45 minutes before the ED staff realized Patient #15 eloped from the ED. Review of the medical record revealed Patient #16 presented to the ED on 06/05/2024 at 2:10 p.m. with a complaint of lower abdominal pain. Patient #16 was triaged with an acuity level of three (3) and the MSE was initiated by NP #1 at 2:36 p.m. Lab and imaging testing was ordered, and after testing patient #16 was sent back to the ED lobby at 2:53 p.m. Medical record review revealed there is no documented evidence of an attempted/patient encounter until 06/06/2024 at 1:32 a.m. Medical record review revealed the patient went without staff contact for 11 hours and 38 minutes before the ED staff realized the patient eloped from the ED. An interview with NP #1 on 06/13/24 at 4:45 p.m. confirmed Patients #1, #10, #13, #14, #15, and #16 were triaged, had an initiated MSE and testing, then sent back to the ED lobby to wait for test results and completion of the MSE/treatment plan on 06/05/2024. NP #1 also confirmed there was no documented evidence of the patients being reassessed/monitored by an ED staff member after testing. An interview with the Director of Quality (DOQ), on 06/13/2024 at 5:20 p.m. also confirmed patients #1, #10, #13, #14, #15, and #16 were triaged, had an initiated MSE and testing, then sent back to the ED lobby to wait for test results and completion of the MSE/treatment plan on 06/05/2024. Additionally, the DOQ confirmed there was no documented evidence of the patients being reassessed/monitored by an ED staff member after testing. Review of the ED log dated 06/05/2024 revealed 29 of 171 patients seeking medical assistance left without being seen, left after triage, eloped, or left against medical advice. Review of document titled, “Surge Capacity Plan,” dated 02/21/2023 submitted by ED Director reveals the ED unit has a plan for monitoring the influx of patients into levels of 3 categories; Level 1 Yellow Extremely busy, not overcrowded, 61-100 patients; Level 2 Red Overcrowded to Extremely Overcrowded,101-180 patients; Level 3 Black Dangerously Overcrowded, 181-260 patients. The plan includes an “NEDOCS Tracking Log” to be documented daily to score surge levels. The Emergency Department ED log revealed the ED was at “Level Two (2) [based on ED log census of 171] - Red (NEDOCS 101-180) Overcrowded to Extremely Overcrowded” defined roles and responsibilities included “ ...Make reassignments change RN [Registered Nurse] Ratios ...non-bedside nurses to assist in ED ...evaluate alternative treatment spaces ...Assign additional staff to ED ...Waiting Room - vitals up to date ...Need Personal Care Assistant, (PCA) ...Ongoing evaluation of NEDOCS score every 2hours ...” The facility had no documented evidence of activation/implementation of their “Surge Capacity Plan” for the Emergency Department, no documented evidence of the “NEDOCS Tracking Log” completed per plan, and no evidence of deploying additional staff/resources to the ED on 06/05/2024. Interview with Director of Quality Review (DQR) on 06/14/2024 at 12:10 p.m. confirmed the facility failed to document the required information on the facility’s NEDOCS tracking log per the “Surge Capacity Plan” on 06/05/2024. Review of the facility policy and procedure titled, “Diversion”, dated last revision 09/2021, revealed, “...Purpose...The goal of the ED is to provide appropriate and expeditious treatment to all who seek medical care...Policy...In the event that demand exceeds resources in the ED the house supervisor is notified, and resources are moved to the ED to meet patient needs...”. The facility failed to implement/follow its “Diversion Policy” when demand exceeded resources to meet patients’ needs during the ED surge of patients on 06/05/2024. Review of facility policy and procedure titled, “Evaluation and Transfer of Patients with Emergency Medical Conditions”, last revision date 12/2021, revealed “ ...Policy: I. Medical Screening C. Persons requesting examination or treatment for medical conditions are provided an appropriate medical screening examination to determine whether or not they have emergency medical conditions ... E. The initial medical screening and stabilizing treatment includes the use of necessary ancillary services routinely available ...II. Scope of Responsibility A. If a patient is determined to have an emergency medical condition ...further medical examination and treatment may be needed to stabilize the patient. The patient is provided, within capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize the medical condition or transfer the patient ...”. The facility failed to implement its “Evaluation and Transfer of Patients with Emergency Medical Conditions” policy and procedure when the ED had a surge in patients and failed to ensure patients were assessed/monitored for changing conditions while waiting extended times for the completion of their MSE on 06/05/2024. Review of document titled “Assessment/Reassessment Policy” last review/revision date 04/27/2023, revealed established assessment and reassessment time frames for the ED on page three (3) of five (5), “...Patient Care Area...ED... Assessment upon arrival to room after triage and as needed...Reassessments...As indicated by change in patient status...”. The facility policy does not have defined minimum timeframes for assessments/reassessment to ensure patients are monitored for potential deterioration/change in status of their presenting complaints while waiting for the completion of their medical screening. During exit conference on 06/18/2024 with the Director of Risk Management, Director of Quality Review, Chief Nursing Officer and the Chief Executive Officer survey findings were discussed, and no further documents were presented for review. Cross reference A-1104 and A-1112 for additional findings.”

“EMERGENCY SERVICES CFR(s): 482.12(f)(1) If emergency services are provided at the hospital, the hospital must comply with the requirements of §482.55. This Standard is not met as evidenced by: 42806 Based on staff interviews, medical record reviews, policy and procedure reviews, document review of the facility’s Surge Plan, Medical Staff Leadership Council Meeting Minutes, Executive Summary - Surge Plan, Surge Plan Timeline, Surge Capacity Plan Test Change Summary and Recommendations, and the Emergency Department (ED) logs, the Governing Body failed to ensure the emergency services requirement(s) were met for all individuals presenting to the Dedicated Emergency Department (DED) seeking evaluation and treatment for potential emergency medical conditions. The Governing Body failed to ensure the hospital’s surge capacity plan and hospital policies and procedures were implemented and followed on 06/05/2024 when the hospital had high volumes of patients that presented to the DED. Findings Include: Review of the ED log dated 06/05/2024 revealed 29 of 171 patients seeking medical assistance left without being seen, left after triage, eloped, or left against medical advice. Review of document titled, “Surge Capacity Plan,” dated 02/21/2023 submitted by ED Director reveals the ED unit has a plan for monitoring the influx of patients into levels of 3 categories; Level 1 Yellow Extremely busy, not overcrowded, 61-100 patients; Level 2 Red Overcrowded to Extremely Overcrowded,101-180 patients; Level 3 Black Dangerously Overcrowded, 181-260 patients. The plan includes a “NEDOCS Tracking Log” to be documented daily to score surge levels. The Emergency Department logs for 06/05/2024 revealed the ED was at “Level Two (2) [based on ED census of 171 patients] - Red (NEDOCS 101-180) Overcrowded to Extremely Overcrowded” defined roles and responsibilities included “...Make reassignments change RN [Registered Nurse] Ratios ...non-bedside nurses to assist in ED ...evaluate alternative treatment spaces ...Assign additional staff to ED ...Waiting Room - vitals up to date ...Need Personal Care Assistant, (PCA) ...Ongoing evaluation of NEDOCS score every 2 hours ...” The facility had no documented evidence of the it’s activation/implementation of “Surge Capacity Plan” for the Emergency Department, no documented evidence of the “NEDOCS Tracking Log” completed per hospital plan, and no evidence of deploying additional staff/resources to the ED on 06/05/2024. During exit conference on 06/18/2024 with the Director of Risk Management, Director of Quality Review, Chief Nursing Officer and the Chief Executive Officer, survey findings were discussed, and no further documents were presented for review. Cross reference to A-043, A-263 and A-1100 for additional findings.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 42806 Based on staff interviews, medical record reviews, policy and procedure reviews, document review of the facility’s Surge Plan, Medical Staff Leadership Council Meeting Minutes, Executive Summary - Surge Plan, Surge Plan Timeline, Surge Capacity Plan Test Change Summary and Recommendations, and the Emergency Department (ED) logs, the hospital failed to take actions to improve throughput of patients presenting to the Dedicated Emergency Department (DED) after identifying its surge capacity plan, pathways and protocols for defined surge levels were not consistently implemented to meet the needs of the community. This affected six (6) of 20 sampled patients and had the potential to affect all patients presenting to the DED requesting evaluation and treatment, (Patients #1, #10, #13, #14, #15, and #16). Findings Include: An interview with the Director of Quality Review (DQR) on 06/13/2024 at 2:20 p.m. confirmed the facility’s “Surge Capacity Plan” was approved 02/11/2020 and at the time of the survey a Performance Improvement Project (PIP) was in place to pilot some changes. An interview with the Chief Nurse Officer (CNO) on 06/14/2024 at 12:05 p.m. confirmed the facility has an active “Surge Capacity Plan” and a pending revision to the plan. The CNO stated, “We are still trying to gather consistent National Emergency Department Overcrowding Scores (NEDOCS) from our charge nurses and then consistently follow up from those scores.” Review of facility document titled, “Medical Staff Leadership Council” meeting minutes dated 02/11/2020 revealed the ED Surge Plan submitted by the Quality Director was approved by the council and a motion was made and seconded to accept the ED surge plan and flowcharts which will enable the facility to proactively respond to the unexpected surges in patient volume, inefficient movement of admitted patients out of the ED and the lack of throughput within the ED. Review of a hospital document titled “Executive Summary - Surge Plan” dated 01/25/2023, revealed the hospital has a plan intended to serve as a tool to proactively respond to the unexpected surges in patient volume, inefficient movement of admitted patients out of the ED, and the lack of throughput within the ED. Under the “Background” section of the document it stated, “Overcrowding impacts the bottom line of our organization through lost revenue, poor patient experience, and community reputation. ED Crowding is not the ED’s burden to bear alone, it is a hospital problem. Facilitating patient flow is everyone’s job in the hospital. Having a Surge Plan can help improve patient flow and throughput.” The “Surge Plan” section documented “The Surge Plan is intended to serve as a tool to proactively respond to unexpected surges in patient volume, inefficient movement of admitted patients out of the ED and the lack of throughput within the ED. The National Emergency Department Overcrowding Score (NEDOCS) will be used to trigger the activity by hospital team members to help mitigate crowding. The ED Charge Nurse will provide the NEDOCS for the Daily Hospital Safety Huddle and throughout the day as necessary.” Review of documented titled “Surge Plan Timeline” revealed a Surge Plan review timeline for improvements with Senior Leader Presentation 02/14/2023, Director/Managers Presentation 02/21/2023, Test of Change March 06-13, 2023, Evaluate March data April 10-14, 2023, and Re-evaluate and make changes and present data to director/managers to hardwire process by 04/18/2023. Review of document titled, “Surge Capacity Plan Test of Change Summary and Recommendations”, dated with most recent date of 07/21/2023 revealed no further documentation on improvements of surge plans submitted since 07/21/2023, no approval of changes, and no recent tracking and trending of outcomes. The facility had no documented evidence of the activation/implementation of “Surge Capacity Plan” for the Emergency Department on 06/05/2024 and no documented evidence of the “NEDOCS Tracking Log” completed per their “Capacity Surge Plan” on 06/05/2024. During exit conference on 06/18/2024 with the Director of Risk Management, Director of Quality Review, Chief Nursing Officer and the Chief Executive Officer survey findings were discussed, and no further documents were presented for review. Cross reference to A-263, A-309 and A-1100 for additional findings.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 42806 Based on staff interviews, medical record reviews, policy and procedure reviews, document review of the facility’s Surge Plan, Medical Staff Leadership Council Meeting Minutes, Executive Summary - Surge Plan, Surge Plan Timeline, Surge Capacity Plan Test Change Summary and Recommendations, and the Emergency Department (ED) logs, the hospital’s Governing Body failed to ensure actions to improve throughput of patients presenting to the Dedicated Emergency Department (DED) according to the surge capacity plan, pathways and protocols for defined surge levels, were implemented and evaluated to meet the needs of the community ensuring patients presenting to the Dedicated Emergency Department (DED) were evaluated by a Qualified Medical Person (QMP) to determine if individuals on the hospital campus had an emergency medical condition that required treatment by a member of the medical staff. This affected six (6) of 20 patients sampled and had the potential to affect all patients presenting to the DED, (Patients #1, #10, #13, #14, #15, and #16). Findings Include: Review of a hospital documented titled “Surge Plan Timeline” revealed a timeline for improvements with Senior Leader Presentation 02/14/2023, Director/Managers Presentation 02/21/2023, Test of Change March 06-13, 2023, Evaluate March data April 10-14, 2023, and Re-evaluate and make changes and present data to director/managers to hardwire process by 04/18/2023. Review of the facility document titled, “Surge Capacity Plan Test of Change Summary and Recommendations”, dated 07/21/2023, revealed a test was launched March 6-31, 2023, and extended through May and June 2023 with findings and recommendations. There was no further documentation submitted to indicate recommendations were presented to Senior leaders, approval of changes, performance improvement projects implemented, and no recent tracking and trending of outcomes with the Surge Capacity Plan since 07/21/2023. The facility did not implement its “Surge Capacity Plan” or record the NEDOCS data used to trigger the initiation of the plan on 06/05/2024. During exit conference on 06/18/2024 with the Director of Risk Management, Director of Quality Review, Chief Nursing Officer and the Chief Executive Officer survey findings were discussed, and no further documents were presented for review. Cross reference to A-263 and A-1100 for additional findings.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 42806 Based on staff interview, medical record review, facility policy and procedure review, and review of the facility’s documents Emergency Department (ED) logs, and Surge Capacity Plan, the hospital failed to implement its own policy and procedures related to diversion to expedite medical screening examinations (MSE) for individuals presenting to the ED seeking treatment for potential emergency medical conditions. The hospital failed to deploy additional resources to the ED on 06/05/2024 to ensure patient needs were met. This affected six (6) of 20 patients sampled and had the potential to affect all patients presenting to the Dedicated Emergency Department (DED), Patients #1, #10, #13, #14, #15, and #16. Findings Include: Review of the facility policy and procedure titled, “Triage Acuity Classification System Problem Specific Guidelines,” dated last review of 05/2022, revealed each patient presenting to the ED requesting emergency services is triaged and receives a MSE by the ED physician or his/her designees (Nurse Practitioner or Physician’s Assistant) ... facility uses the 5-level Emergency Severity Index (ESI) triage leveling system...”. The algorithm does not include time frames for initiating care except for Level one (1), immediate life-saving interventions required, Level two (2) is High Risk Situation, would put in last open bed, Level three (3) many resources needed (testing). Review of the ED log dated 06/05/2024 revealed 29 of 171 patients seeking medical assistance left without being seen, left after triage, eloped, or left against medical advice. Review of the facility policy and procedure titled, “Diversion”, dated last revision 09/2021, revealed, “...Purpose...The goal of the ED is to provide appropriate and expeditious treatment to all who seek medical care...Policy...In the event that demand exceeds resources in the ED the house supervisor is notified, and resources are moved to the ED to meet patient needs...”. The facility failed to implement/follow its “Diversion Policy” when demand exceeded resources to meet patients’ needs during the ED surge of patients on 06/05/2024. Review of facility policy and procedure titled, “Evaluation and Transfer of Patients with Emergency Medical Conditions”, last revision date 12/2021, revealed “ ...Policy: I. Medical Screening C. Persons requesting examination or treatment for medical conditions are provided an appropriate medical screening examination to determine whether or not they have emergency medical conditions ... E. The initial medical screening and stabilizing treatment includes the use of necessary ancillary services routinely available ...II. Scope of Responsibility A. If a patient is determined to have an emergency medical condition ...further medical examination and treatment may be needed to stabilize the patient. The patient is provided, within capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize the medical condition or transfer the patient ...”. The facility failed to implement its “Evaluation and Transfer of Patients with Emergency Medical Conditions Policy” when the ED had a surge in patients and were unable to provide the completion of medical examinations and treatments as required to stabilize the medical condition of patients with extended waiting times. Review of document titled “Assessment/Reassessment Policy” last review/revision date 04/27/2023, reveals established assessment and reassessment time frames for the ED on page three (3) of five (5), “...Patient Care Area...ED... Assessment upon arrival to room after triage and as needed...Reassessments...As indicated by change in patient status...”. The facility policy does not have defined minimum timeframes for assessments/reassessment to ensure patients are monitored for potential deterioration/change in status of their presenting complaints while waiting for the completion of their medical screening An interview with facility ED Director on 06/12/2024 at 3:15 p.m. to 3:40 p.m. confirmed on 06/05/2024 the hospital census was at capacity and their ED census was 171, which included a high rate of critical holds. When questioned about facility protocols when at capacity, the ED Director confirmed they have a “Surge Capacity Plan,” which is activated to try to mitigate long wait times and delays in care, and further confirmed she does not recall activating the surge plan on that day. The ED Director could not confirm the ED was provided additional staff or other resources to monitor waiting patients for deterioration of their presenting complaints or that the facility implemented its “Diversion Policy” or “Evaluation and Transfer of Patients with Emergency Medical Conditions Policy” to ensure patient needs were met. An interview with ED Charge Nurse on 06/12/2024 at 4:20 p.m. confirmed she was working as charge nurse on 06/05/2024. The ED Charge Nurse does not recall implementing the surge plan or script announcement on 06/05/2024 related to the facility being at capacity. Further interview revealed the ED Charge Nurse could not confirm the ED was provided with additional staff or other resources to ensure ongoing assessment of waiting patients and could not submit any documented evidence of ongoing assessment of waiting patients. An interview with the Director of Quality Review (DQR) on 06/13/2024 at 2:20 p.m. confirmed the facility’s “Surge Capacity Plan” was approved 02/11/2020 and at the time of the survey had a performance improvement project (PIP) in place to pilot some changes. The DQR also confirmed the ED director reported she did not recall utilizing/implementing the “Surge Capacity Plan” on 06/05/2024. The DQR could not confirm the facility provided additional staff or other resources to monitor waiting patients for deterioration of their presenting complaints or that the facility implemented its “Diversion Policy” or “Evaluation and Transfer of Patients with Emergency Medical Conditions Policy” to ensure patient needs were met. An interview with Nurse Practitioner (NP) #1 on 06/13/24 at 4:45 p.m. confirmed Patients #1, #10, #13, #14, #15, and #16 were triaged, had an initiated MSE and testing, then sent back to the ED lobby to wait for test results and completion of the MSE/treatment plan on 06/05/2024. Additionally, NP #1 stated there was no documented evidence of the patients being reassessed/monitored by an ED staff member after testing. In a follow up interview with the Director of Quality (DOQ), on 06/13/2024 at 5:20 p.m. it was also confirmed Patients #1, #10, #13, #14, #15, and #16 were triaged, had an initiated MSE and testing, then sent back to the ED lobby to wait for test results and completion of the MSE/treatment plan on 06/05/2024. DOQ confirmed there was no documented evidence of the patients being reassessed/monitored by an ED staff member after testing. An interview with the Chief Nurse Officer (CNO) on 06/14/2024 at 12:05 p.m. confirmed the facility has an active “Surge Capacity Plan” and a pending revision to the plan. The CNO stated, “We are still trying to gather consistent National Emergency Department Overcrowding Scores (NEDOCS) from our charge nurses and then consistently follow up from those scores.” The CNO confirmed the facility had a “Capacity Call” at 8:00 a.m. on 06/05/2024 to review the following: current house wide census, which was around 305, current ED holds, which was around 17 holds, the type of available staffed beds, which was zero (0), any scheduled operating room cases that will need beds, any Intensive Care Unit (ICU) cases that could be stepped down, which was zero (0) for the day, any step-downs that could go to medical-surgical (M/S) unit, Nurse patient ratios: M/S one (1) nurse to eight (8) patients (1:8), fully staffed, Stepdown ratio 1:4-5, ICU 1:2-3 with about 28-30 census, Critical Care Unit (CCU) 1:1. The CNO said a “snapshot of the census” is obtained at 5:30 a.m. or 6:30 a.m. so it can be reviewed and discussed at the “Capacity Call”. The CNO could not confirm or provide any evidence that the facility deployed additional staff or other resources to the ED to ensure ongoing assessment/monitoring of patients for the potential deterioration of their presenting complaints, while waiting for extended periods of time in the ED waiting room for an open ED bed to complete their medical screening exam (MSE) or that the facility followed its “Diversion Policy” when at capacity. In an interview with the Director of Quality Review (DQR) on 06/14/2024 at 12:10 p.m. it was confirmed the facility did not document the required data in the NEDOCS tracking log to score surge levels was implemented per the “Surge Capacity Plan” on 06/05/2024. The DQR further confirmed the facility has a daily 8:00 a.m. “Capacity call” to discuss the “snapshot census report” and patient movement, and at 8:15 a.m. all nurse leaders have a “huddle meeting” to discuss patient acuity, moves, safety initiatives such as restraints and one (1) on one (1) (1:1) patient needs, lines, foleys [catheters], pending tests, and surgeries. The DQR confirmed this was part of surge management and satisfied the surge plan. However, the facility did not implement/follow the surge plan. Review of a hospital document titled, “Surge Capacity Plan,” dated 02/21/2023 submitted by ED Director revealed the ED unit has a plan for monitoring the influx of patients into levels of three (3) categories; Level 1 Yellow Extremely busy, not overcrowded, 61-100 patients; Level 2 Red Overcrowded to Extremely Overcrowded,101-180 patients; Level 3 Black Dangerously Overcrowded, 181-260 patients. The plan includes an “NEDOCS Tracking Log” to be documented daily to score surge level. A hospital document titled The Emergency Department Surge Plan Job Action Sheet for “Level Two (2) - Red (NEDOCS 101-180) Overcrowded to Extremely Overcrowded” defined roles and responsibilities included “ ...Make reassignments change RN [Registered Nurse] Ratios ...non-bedside nurses to assist in ED ...evaluate alternative treatment spaces ...Assign additional staff to ED ...Waiting Room - vitals up to date ...Need Personal Care Assistant, (PCA) ...Ongoing evaluation of NEDOCS score every 2hours ...” for condition yellow and increasing to NWDOCS score every two (2) hours for condition red (Overcrowded) ...”. Review of the facility policy and procedure titled, “Diversion”, dated last revision 09/2021, revealed, “...Purpose...The goal of the ED is to provide appropriate and expeditious treatment to all who seek medical care...Policy...In the event that demand exceeds resources in the ED the house supervisor is notified, and resources are moved to the ED to meet patient needs...”. The facility failed to follow its “Diversion Policy” on 06/05/2024 when the facility was at capacity with a surge of ED patients and put the safety of patients in the ED at risk as well as the community if there was a disaster event that would have required hospital services. Review of facility policy and procedure titled, “Evaluation and Transfer of Patients with Emergency Medical Conditions”, last revision date 12/2021, revealed “ ...Policy: I. Medical Screening C. Persons requesting examination or treatment for medical conditions are provided an appropriate medical screening examination to determine whether or not they have emergency medical conditions ... E. The initial medical screening and stabilizing treatment includes the use of necessary ancillary services routinely available ...II. Scope of Responsibility A. If a patient is determined to have an emergency medical condition ...further medical examination and treatment may be needed to stabilize the patient. The patient is provided, within capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize the medical condition or transfer the patient ...”. The facility failed to implement its policy and procedure “Evaluation and Transfer of Patients with Emergency Medical Conditions”, on 06/05/2024 when the ED had a surge in patients and the facility was at capacity to ensure patients were assessed/monitored for changing conditions while waiting extended times for the completion of their MSE on 06/05/2024. There was no documented evidence of the facility’s activation/implementation of “Surge Capacity Plan” for the Emergency Department on 06/05/2024 or deployment of additional staff or resources affecting six (6) of 20 patients sampled and had the potential to affect all patients presenting to the Dedicated Emergency Department (DED). During exit conference on 06/18/2024 with the Director of Risk Management, Director of Quality Review, Chief Nursing Officer and the Chief Executive Officer survey findings were discussed, and no further documents were presented for review. Cross reference to A-1100 and A1112 for additional findings.”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 42806 Based on staff interview, medical record review, facility policy and procedure review, and review of the facility’s documents Emergency Department (ED) logs, Surge Capacity Plan, the hospital failed to deploy additional staff to the Dedicated Emergency Department on 06/05/2024 to ensure its own emergency policies and procedures were implemented and followed during patient surges. This affected six (6) of 20 sampled patients and had the potential to affect all patients served, (Patients #1, #10, #13, #14, #15, and #16). Findings Include: There was no documented evidence of the facility’s activation/implementation of “Surge Capacity Plan” for the Emergency Department on 06/05/2024 or deployment of additional staff or resources affecting six (6) of 20 patients sampled and had the potential to affect all patients presenting to the Dedicated Emergency Department (DED). During exit conference on 06/18/2024 with the Director of Risk Management, Director of Quality Review, Chief Nursing Officer and the Chief Executive Officer survey findings were discussed, and no further documents were presented for review. Cross reference to 1100 and A1104 for additional findings.”